DEVOTED CHOICE GIVEBACK 005 HI (PPO)

DEVOTED CHOICE GIVEBACK 005 HI (PPO) is a PPO plan offered by Devoted Health, Inc. available for enrollment in 2025 to people living in Honolulu, Kauai Counties. This plan received an overall rating of 3.5 out of 5 stars in 2026.

It's important to know that DEVOTED CHOICE GIVEBACK 005 HI (PPO) is a Medicare Advantage (MA) Plan with drug coverage. That means that this plan covers both medical services and prescription drugs.

Key Plan Facts

Below are a few key facts and commonly-asked questions about DEVOTED CHOICE GIVEBACK 005 HI (PPO).

Plan Costs:

The cost of a Medicare Advantage Plan is made up of four main parts.

• First, the monthly premium — the amount you pay every month.
• Second, the deductible — the amount you pay out of pocket for covered services before the plan starts paying.
• Third, the copayments and coinsurance — the amounts you pay out of pocket for covered services, usually after meeting the deductible (if applicable). Copays are fixed dollar amounts; coinsurance is a percentage of the cost.
• Fourth, the Out-of-Pocket Maximum — the maximum amount you could have to pay out of pocket in a year. This may be different for in-network and out-of-network services.

You can see below for the coinsurance and specific copayments for in the Additional Benefits section below, or refer to our Plan Details page for more details.

Common Services:

Drug Coverage

The DEVOTED CHOICE GIVEBACK 005 HI (PPO) Medicare plan features an annual drug deductible of $605 and offers no copay for Tier 1 preferred generic drugs filled at standard pharmacies or through standard mail order. For Tier 2 generic medications, beneficiaries pay a low copay starting at $1.00 for a one-month supply at standard pharmacies and standard mail order. A three-month supply of Tier 2 generic drugs costs a $3.00 copay at standard pharmacies and a $2.50 copay through standard mail order. Higher-tier medications are subject to coinsurance, with Tier 3 preferred brand drugs requiring a 24% coinsurance for all supply durations. Tier 4 non-preferred drugs and Tier 5 specialty drugs both require a 25% coinsurance for a one-month supply at standard pharmacies and standard mail order. This drug plan structure offers highly affordable options for everyday generics while sharing the cost of brand-name and specialty medications through coinsurance.

Additional Benefits

The DEVOTED CHOICE GIVEBACK 005 HI (PPO) plan offers robust coverage with no copay for primary care visits, preventive services, and home health care. For specialist visits, members pay a $55 copay, while inpatient hospital stays require a $475 daily copay for the first four days followed by no copay for days 5 through 90. Emergency room visits carry a $115 copay, which is waived if you are admitted, and outpatient services feature copays ranging from no copay up to $575 with no coinsurance. For supplemental care, routine eye exams and select dental services feature no copay up to set annual maximums, though Medicare-covered dental and hearing exams require a $55 copay. Skilled nursing facility stays have no copay for the first 20 days, after which a $218 daily copay applies through day 100. Additionally, durable medical equipment is covered with no copay and a 20% coinsurance, helping keep your out-of-pocket medical costs predictable.